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Home dialysis and the lengthy wait for a kidney transplant

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The Question: I want to do dialysis at home but am worried. Is it safe? Is it possible?

The Answer: This is the kind of question Alireza Zahirieh, head of home hemodialysis at Sunnybrook, encounters all the time from patients. The vast majority of them are waiting for kidney transplants – some up to a decade. In the interim, they face coming to hospital for at least four hours a day, three days a week, until they receive a new organ.

“Virtually every patient is a candidate for hemodialysis,” Dr. Zahirieh, staff nephrologist said in an interview. “When we see someone who is starting (this form) of life support, we try to get them as much education as possible.”

With hemodialysis, a machine and special filter are used to clean the blood. To draw the blood, a doctor either inserts a special intravenous catheter in a large vein, usually in the neck or surgically connects a vein to an artery to create what is known as a fistula, which can be needled or accessed during each dialysis session. The blood is withdrawn from the body and then passed through a dialyzer, an artificial kidney.

Of the 39,352 people across Canada living with end-stage renal disease, 23,188 were on dialysis and 16,164 were living with a functioning kidney transplant, according to 2010 figures from the Canadian Organ Replacement Register, the latest available.

“For someone to do hemodialysis at home, they have to be able to set up the machine, they have to be able to connect themselves to the machine,” said Dr. Zahirieh. “It may involve putting two needles in their fistula, finding the right spot and making sure the blood is flowing. On the machine, they have to know how to take the right amount of fluid out of their body.”

In addition, they also need to monitor their treatment and then be able to do everything in reverse.

The bulk of patients with end stage renal failure are those with diabetes and renal vascular disease.

Usually, patients are put on dialysis when their kidney function is less than 10 per cent of an average 20-year-old. Symptoms are slow to develop and include nausea, loss of appetite, weight loss, itching, swelling and high blood pressure.

There are several hemodialysis options at home. In broad terms, dialysis can either be done during the day or done at night, while a patient is asleep. Most patients either choose to do intermittent hemodialysis, which is done every other day or nocturnal hemodialysis, which takes place overnight, four to six nights a week. By comparison, patients who receive their treatments in hospital typically spend four hours on the machine three days a week.

“The typical [home dialysis] patient is younger and healthier than the average patient in our unit,” he said, noting that patients doing home dialysis range from their 30s to their 70s.

Either way, it is significant investments in time and patients have to be motivated to undergo the six to eight weeks of training. Patients have to be able to insert needles, properly clean equipment and use the machines, noted Dr. Zahirieh, Assistant Professor of Medicine at the University of Toronto.

“In comparison to the alternative form of home based dialysis [peritoneal dialysis] hemodialysis takes a lot of training, involves a lot of monitoring and is the most involved form of dialysis,” he said.

“This can really limit the number of people who choose to do it. However, I believe it offers a number of unique benefits. It can dramatically reduce and even eliminate some dietary constraints, improve fertility, lead to improvements in heart health and possibly overall health as compared to other forms of dialysis.”

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.